How To Write A Marie Talty Case Studies
Case Report Marie Talty
HISTORY
N.C. a 26 year old woman para 4+3, gravida 8, at 26 weeks gestation with dichorionic dimniotic (DCDA) twins, presented to the Admissions department of Obstetrics and Gynaecology on 4th Septmember (Thursday) with a 24 hour history of crampy ‘tightening’ abdominal pain and decreased fetal movements. She had last noticed fetal movements on Wednesday morning. She said that the pain which was in the suprapubic region was more like a tightening and rated the severity as about 6/10 at worst. It had begun during Wednesday evening and she had taken no pain relief e.g. paracetemol. The pain was worse on micturition and had no relieving factors, it also did not radiate anywhere. There was no per vaginal bleeding at …show more content…
any stage. She also had not experienced any unusual or foul smelling discharge and was apyrexic. Her antepartum history was significant for discordant growths between the twins noted at 12weeks but this had since resolved. Upon ultrasound, fetal heart activity was absent in both foetuses, both of which were in cephalic position with high placentas (one anterior, one posterior) and normal amniotic fluid.
Prenatal History and Examination
History of index pregnancy:
• Last menstrual period 25th February 2014.
• Estimated date of delivery 2nd December 2014.
• N.C. is O Rhesus negative blood group.
• Her booking visit was at 10 weeks, her booking weight was 51kg (BMI 18.1) and she was counselled on stopping smoking as well as improving her diet and taking vitamin supplements.
• Her first scan at 12 weeks showed a DCDA twin pregnancy with discordant growths, with there being a 22% difference in the sizes of the twins. Fetal heart activity was present and there was normal amniotic fluid.
• On the 16th week scan this was shown to have resolved with the twins being of more similar sizes, both were deemed “small for dates” though. Fetal heart activity was present.
• On the 20 week scan no fetal anomalies were found and fetal growth was again cordant although again in the lower centiles for the gestational age.
• N.C. was hospitalised in early August for right upper quadrant abdominal pain, radiating to the back, no evidence of any liver dysfunction was found and the pain resolved and she was discharged. She described that pain as very different to this one which was more of a discomfort. She also received two doses of corticosteroids on that admission.
• During this pregnancy N.C. had suffered from backache, breast tenderness and tiredness though none were incredibly severe.
Obstetric History:
N.C. has previously delivered 4 live children and has also had 3 spontaneous abortions.
• June 2008-Complete spontaneous abortion at 8 weeks, she did was away in England at the time and did not see any health care professional until she visited her GP on her return. No anti-D antibodies were received.
• November 2008-Incomplete spontaneous abortion at 10 weeks. An evacuation of retained products of conception (ERPC) was performed and she received anti D.
• February 2010- Male infant was delivered at 36 weeks of gestation weighing 2380g. It was an induced labour with vacuum extraction, due to maternal pre eclamptic toxaemia (PET).
• March 2011-Male infant was delivered 34+6 weeks of gestation weighing 1580g. It was an Emergency C Section following CTG suggesting placental abruption as well as maternal PET. Placental abruption was found. The baby was admitted to NICU but has no remaining health problems.
• March 2012- Female infant was delivered at 35 weeks of gestation weighing 2000g. It was an Emergency C section due to suspicious CTG in context of maternal PET, baby was admitted to NICU but has no long lasting health problems.
• March 2013 Male infant was delivered at 36 weeks gestation weighing 1800g. This was by Emergency C section due to suspicious CTG. The baby had IUGR admitted to NICU but has no remaining health problems.
• January 2014- Complete spontaneous abortion at 8 wks. This was at home and N.C. did not receive any anti-D.
Gynaecological History
• N.C had her last menstrual period on 25th February 2014.
• She underwent menarche at age 13.
• Her menses are regular every 28-30 days, lasting for 5 days. She never experienced dysmenorrhea or menorrhagia.
• N.C. last had a smear test in 2013 which had normal findings.
• She has previously tried the Mirena and copper coils for contraception but developed infections. She does not wish her use of contraception to be known by her partner so this limits her options in this regard.
Medications
• No known drug allergies (NKDA)
• Not on any regular medications.
• She had previously taken labetalol for pregnancy induced hypertension but that was not an issue in this pregnancy.
Past Medical History
N.C. has previously had candida, chickenpox as well as a history of migraine. She also says she had a heart murmur as a baby but that this resolved without treatment.
Past Surgical History
N.C. has had three previous emergency Caesarean sections.
Family History
N.C.’S father has type 1 diabetes, as well as a history of 2x Cerebrovascular Accident and 3x Myocardial Infarction.
Social History
N.C. is a member of the Travelling Community. She lives with her partner and four children and she is currently unemployed. She continued to smoke 3 cigarettes a day during pregnancy, cutting down from her prenatal 10 a day. She had occasional alcohol intake before pregnancy but none during.
DISCUSSION
N.C.’s care encompassed many issues that I will try to discuss here including the following:
• The effects of maternal smoking on birth outcome
• Complications of multiple pregnancy
• Previous placental abruption as a risk factor for another
• Indications for anti D administration in rhesus negative pregnant women
• Stillbirth management
N.C. a previous smoker of 10 cigarettes a day, attempted to quit but continued to smoke 3 cigarettes a day during this pregnancy. What pregnancy complications does this increase her risk of and how may pregnant women be encouraged to quit smoking during pregnancy?
It is well established that cigarette smoking has many adverse effects during pregnancy.(1) This includes spontaneous abortion, ectopic pregnancy, placental abruption, low birth weight babies, preterm premature rupture of membranes (PPROM), preterm labour and delivery and placenta previa.(2) It is quite evident in N.C.’s past obstetric history that she has had quite a number of these complications in the past, suffering 3 spontaneous abortions and having 4 babies born with birth weights below the average for their gestational age.
She has also had a previous placenta l abruption as well as the double placental abruption in this pregnancy. She also had all of her babies before term and one must wonder if some of these complications could have been avoided if N.C. had received more support and counselling in her attempt to quit smoking in each pregnancy. I know that during each pregnancy she tried to stop completely but ended up continuing to smoke a couple of cigarettes each day. She never tried any nicotine replacement therapy and I wonder if her G.P. should have done more to encourage this as this would be of great benefit in her attempt to quit completely.(3) This would have had a very positive impact on her pregnancies as well as her general health and her many complications would perhaps have been less likely if she had succeeded.
(3)
A multiple pregnancy, in this case, twins, increases the risk of many complications during pregnancy and so requires very careful management. How was this managed in N.C.’s case?
Once a multiple pregnancy has been diagnosed, hopefully before 14 weeks as was the case in this case, the type of twin pregnancy should be confirmed.(4) Twin pregnancies also require very close hospital based surveillance with regular scans(2, 4, 5), and N.C. received such care. Multiple pregnancies pose increased risk of fetal preterm birth, perinatal mortality, congenital abnormalities and obviously twin-twin transfusion syndrome is an important concern in monochorionicity.(5) There is also an increased risk of maternal complications e.g. postpartum haemorrhage, gestational diabetes mellitus and pregnancy induced hypertension, etc.(2, 5) Also a clear delivery plan should be made,(4) this had not yet been done in N.C.’s case due to her gestational age. A suspected twin-twin growth discordance of greater than 22% is an indication for care at a tertiary centre and N.C. was already receiving such care in Galway so no referral was needed.(4)
N.C. had previously had a placental abruption, which certainly predisposes her to another, what other risk factors were present and was the diagnosis made in a reasonable amount of time?
Placental abruption in a previous pregnancy is the most predictive predisposing factor to having another abruption. (6) A large Norwegian observational study reported a 4.4% rate of recurrent abruptions although some sources report this as up to 6%.(7) In those who have had 2 previous pregnancies complicated by placental abruption this increases to up to 25%(8). Other risk factors include pre-eclampsia, polyhydramnios, IUGR, low body mass index (BMI), multiparity, smoking, trauma and premature rupture of membranes(6). Certainly N.C. had several of these as she was had a previous abruption, was highly parous, smoked during her pregnancy, had an underweight BMI and had small for dates babies. Once N.C. presented to Admissions after visiting her GP on the Thursday, she was promptly sent for ultrasound where it was found that intra-uterine death had occurred of both foetuses. As such I don’t believe the diagnosis could have been made much quicker and I certainly feel that she was identified as a patient at high risk for placental abruption and treated as such(3). Unfortunately it was too late and therefore the management couldn’t really change.
N.C. a pregnant woman with the blood group O rhesus negative, has received anti-D antibodies in the past after certain potentially sensitising events, e.g. after ERPC, but did not after d2 of her miscarriages. What are the indications for administration of anti-D to pregnant women and were these followed in her management.
According to the RCPI guidelines, anti-D should only be given to women who are not already sensitised as it cannot reverse the process(9), and this was the case with N.C. They also state they should be given as soon as possible after the sensitising event, at least within 72 hours.(9) Even if this dose is missed they recommend giving the anti-D up to 10 days after the possibly sensitising event.(9) There is a list of potentially sensitising events after which anti-D must be given. These include: termination of pregnancy (medical or surgical), threatened or complete spontaneous abortion after 12 weeks, ectopic pregnancy, antepartum haemorrhage, invasive procedures such as amniocentesis, chorion villus sampling, fetal blood sampling, external version of the fetus, intrauterine death and stillbirth.(9, 10) This explains why N.C. did not receive anti-D after two of her miscarriages as they were before 12 weeks, and the one after which she did required an invasive procedure and so she received it in that case. She also received it after her stillbirth, which was appropriate. (9, 10)
I certainly learnt a lot from this case about management of an obviously very tragic case of stillbirth both in a more biological sense and obviously dealing with the patient and their family’s grief and coping with it.
Certainly the diagnosis of a stillbirth is one of the most tragic things that can happen to a woman and her partner, especially when it is so out of the blue. N.C. and her partner had previously suffered several early miscarriages, but the delivery of dead twin babies is clearly an entirely different matter. The news that an intrauterine fetal death has occurred should be delivered in a very unhurried fashion by the doctor looking after the woman and a midwife should be present.(11) It cannot be stressed enough that an IUFD should be treated as as serious a matter as the death of any other close relative and dismissals such as “You’re young you’ll have another”, etc are not appropriate.(12) A plan for delivery should be made as soon as appropriate and this should be in keeping with the woman’s wishes.(11, 13) Methods for induction now can be chosen differently as the effect on the foetus is of less importance.(11) In N.C.’s case a Caesarean section was chosen as it was a twin birth and also due to her three previous C-Sections.(14) In other cases a vaginal birth should often be considered, and also waiting for the woman to labour spontaneously, though this has an associated increased risk of disseminated intravascular coagulation (DIC).(11) Appropriate laboratory tests should be carried out to assess any maternal causes e.g. FBC, coagulation screen, serology for cytomegalovirus, toxoplasma and parvovirus B19, blood group and antibody screen, renal and liver function tests to rule out pre-eclampsia and HELLP syndrome, thyroid function tests and thrombophilia screens are all helpful in deciding if certain conditions attributed to the IUFD.(11) In N.C.’s case she underwent many of these cases even though a working clinical diagnosis of placental abruption had been made and this was found to be the case. It is also the case that fetal karyotyping should be offered as well as autopsy of the foetuses.(11, 13) In N.C.’s case the parents refused the right to a post-mortem as they believed they knew the cause of the stillbirth being placental abruption. This was then clearly taken as their decision and was clearly noted, they were not pressured into reconsidering. A post-mortem examination was still carried out,(11) noting that there were no obvious anomalies as well as noting the foetal weights, lengths, etc. Pathological examination of the cord and placenta was also carried out and the sizes of the clearly abrupted areas were noted.(11) I also noticed that the team were following the GUH checklist for a stillbirth which ensured that all relevant parties e.g. Public Health Nurse, G.P., Coroner; were informed as soon as possible.(11) The parents’ loss I feel was also very well recognised(13) and they received support from the Bereavement Liaison Officer as well as the chaplain. This was very comforting to the family as they wished for their babies to be blessed and for funeral arrangements to be made. Information on all of this was very clearly offered to them, especially through their midwife. N.C. and her partner were encouraged to keep the babies in the room with them as a way of recognising their grief and helping them to deal with it. They were also given the Little Lifetime pack where hand and footprints were taken of the twin boys and also photos taken with both their parents and themselves. I understand they found it difficult to look at these at the time but that they were still keen to have them for the future. A follow-up appointment with the consultant was made for 6 weeks’ time(11) and it was decided that the risks for future pregnancies and plans to conceive, very important in the Travelling Community would not be discussed until then.
REFLECTION
I certainly feel like I learnt a lot from this case both in an academic and also emotional sense. Obviously, I now know more about placental abruption, including risk factors, presentation and management; as well as multiple pregnancy, the impact of maternal smoking on the foetus and also administration of anti-D to rhesus negative women. Also I found out about the guidelines for management of a stillbirth and the clear checklists that they have available in this hospital for such. However I also certainly acquired a lot of practical knowledge about dealing with a patient in severe grief from my very brief encounter with N.C. herself as well as with the entire family. I know understand more about clearly recognising and acknowledging their grief as well as ensuring they have as many momentos, etc as possible for the future. It also really taught me about how quickly things can happen in obstetrics. In this case N.C. was not on the ward on Thursday and only came in late Thursday evening but by the time I saw her on the ward round Friday morning she (and her family) had gone from being very excited about their upcoming new arrivals to the absolute devastation of such a loss. It was pretty clear that while I saw her they were still trying to come to terms with what had happened and they seemed in a state of shock which is why I think the GP and Public Health Nurse have such a key role to play as I think it would often not be until the patient returned home, in this case two days later, that the reality of what had happened would hit and then they need as much support as possible. This is why in cases where the parents are working they should take as much parental leave as possible and this includes the father who can often be forgotten about in these cases. I definitely think that I know a lot more about the “other side” of obstetrics now that is an only too unfortunate reality as 1 in 200 infants in Ireland is stillborn, and I feel this learning experience will make a great impact on my future career as a doctor and also give me much more understanding of this terrible experience. I know that I will never forget the tragic scene in N.C.’s room when I first saw her on that Friday morning and the way in which the whole team did their best to help her sums up to me the my very positive experience on my Obstetrics and Gynaecology rotation.
1. Rodriguez-Thompson Diana MD M. Cigarette Smoking and Pregnancy www.uptodate.com: UpToDate; 2014 [updated 10/09/2014; cited 2014 20/09/2014].
2. Collins S, Arulkumaran S, Hayes K, Jackson S, Impey L. Oxford Handbook of Obstetrics and Gynaecology: OUP Oxford; 2013.
3. Gynaecology RCoOa. Antepartum Haemorrhage. www.rcog.org.uk: Royal College of Obstetrics and Gyanecology, 2011.
4. Institute of Obstetricians and Gynaecologists RCoPoI. Management of Multiple Pregnancy. www.rcpi.ie: Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland, 2014.
5. Impey L, Child T. Obstetrics and Gynaecology: Wiley-Blackwell; 2012.
6. Tikkanen M. Placental abruption: epidemiology, risk factors and consequences. Acta obstetricia et gynecologica Scandinavica. 2011;90(2):140-9.
7. Rasmussen S, Irgens LM, Albrechtsen S, Dalaker K. Women with a history of placental abruption: when in a subsequent pregnancy should special surveillance for a recurrent placental abruption be initiated? Acta Obstetricia et Gynecologica Scandinavica. 2001;80(8):708-12.
8. Steven G. Gabbe JRN, Henry L Galan, Eric R. M. Jauniaux, Mark B Landon, Joe Leigh Simpson, Deborah A Driscoll. Obstetrics: Normal and Problem Pregnancies. 6th ed: Elsevier Health Sciences; 2012.
9. Institute of Obstetricians and Gynaecologists RCoPoI. The use of anti-D immunoglobulin for the prevention of RhD haemolytic disease of the newborn. www.rcpi.ie: Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland, 2014.
10. Gynaecology RCoOa. The Use of Anti-D Immunoglobulin for Rhesus D Prophylaxis. www.rcog.org.uk: Royal College of Obstetrics and Gynaecology, 2011.
11. Institute of Obstetricians and Gynaecologists RCoPoI. Investigation and Management of Late Fetal Intrauterine Death and Stillbirth. www.rcpi.ie: Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland., 2013.
12. Society ISaND. ISANDS Guidelines for Professionals. 1995.
13. Gynaecology RCoOa. Late Intrauterine Fetal Death and Stillbirth. www.rcog.org.uk: Royal College of Obstetrics and Gynaecology
2010.
14. Institute of Obstetricians and Gynaecologists RCoPoI. Delivery after previous Caesarean section. www.rcpi.ie: Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland., 2013.
HISTORY
N.C. a 26 year old woman para 4+3, gravida 8, at 26 weeks gestation with dichorionic dimniotic (DCDA) twins, presented to the Admissions department of Obstetrics and Gynaecology on 4th Septmember (Thursday) with a 24 hour history of crampy ‘tightening’ abdominal pain and decreased fetal movements. She had last noticed fetal movements on Wednesday morning. She said that the pain which was in the suprapubic region was more like a tightening and rated the severity as about 6/10 at worst. It had begun during Wednesday evening and she had taken no pain relief e.g. paracetemol. The pain was worse on micturition and had no relieving factors, it also did not radiate anywhere. There was no per vaginal bleeding at …show more content…
any stage. She also had not experienced any unusual or foul smelling discharge and was apyrexic. Her antepartum history was significant for discordant growths between the twins noted at 12weeks but this had since resolved. Upon ultrasound, fetal heart activity was absent in both foetuses, both of which were in cephalic position with high placentas (one anterior, one posterior) and normal amniotic fluid.
Prenatal History and Examination
History of index pregnancy:
• Last menstrual period 25th February 2014.
• Estimated date of delivery 2nd December 2014.
• N.C. is O Rhesus negative blood group.
• Her booking visit was at 10 weeks, her booking weight was 51kg (BMI 18.1) and she was counselled on stopping smoking as well as improving her diet and taking vitamin supplements.
• Her first scan at 12 weeks showed a DCDA twin pregnancy with discordant growths, with there being a 22% difference in the sizes of the twins. Fetal heart activity was present and there was normal amniotic fluid.
• On the 16th week scan this was shown to have resolved with the twins being of more similar sizes, both were deemed “small for dates” though. Fetal heart activity was present.
• On the 20 week scan no fetal anomalies were found and fetal growth was again cordant although again in the lower centiles for the gestational age.
• N.C. was hospitalised in early August for right upper quadrant abdominal pain, radiating to the back, no evidence of any liver dysfunction was found and the pain resolved and she was discharged. She described that pain as very different to this one which was more of a discomfort. She also received two doses of corticosteroids on that admission.
• During this pregnancy N.C. had suffered from backache, breast tenderness and tiredness though none were incredibly severe.
Obstetric History:
N.C. has previously delivered 4 live children and has also had 3 spontaneous abortions.
• June 2008-Complete spontaneous abortion at 8 weeks, she did was away in England at the time and did not see any health care professional until she visited her GP on her return. No anti-D antibodies were received.
• November 2008-Incomplete spontaneous abortion at 10 weeks. An evacuation of retained products of conception (ERPC) was performed and she received anti D.
• February 2010- Male infant was delivered at 36 weeks of gestation weighing 2380g. It was an induced labour with vacuum extraction, due to maternal pre eclamptic toxaemia (PET).
• March 2011-Male infant was delivered 34+6 weeks of gestation weighing 1580g. It was an Emergency C Section following CTG suggesting placental abruption as well as maternal PET. Placental abruption was found. The baby was admitted to NICU but has no remaining health problems.
• March 2012- Female infant was delivered at 35 weeks of gestation weighing 2000g. It was an Emergency C section due to suspicious CTG in context of maternal PET, baby was admitted to NICU but has no long lasting health problems.
• March 2013 Male infant was delivered at 36 weeks gestation weighing 1800g. This was by Emergency C section due to suspicious CTG. The baby had IUGR admitted to NICU but has no remaining health problems.
• January 2014- Complete spontaneous abortion at 8 wks. This was at home and N.C. did not receive any anti-D.
Gynaecological History
• N.C had her last menstrual period on 25th February 2014.
• She underwent menarche at age 13.
• Her menses are regular every 28-30 days, lasting for 5 days. She never experienced dysmenorrhea or menorrhagia.
• N.C. last had a smear test in 2013 which had normal findings.
• She has previously tried the Mirena and copper coils for contraception but developed infections. She does not wish her use of contraception to be known by her partner so this limits her options in this regard.
Medications
• No known drug allergies (NKDA)
• Not on any regular medications.
• She had previously taken labetalol for pregnancy induced hypertension but that was not an issue in this pregnancy.
Past Medical History
N.C. has previously had candida, chickenpox as well as a history of migraine. She also says she had a heart murmur as a baby but that this resolved without treatment.
Past Surgical History
N.C. has had three previous emergency Caesarean sections.
Family History
N.C.’S father has type 1 diabetes, as well as a history of 2x Cerebrovascular Accident and 3x Myocardial Infarction.
Social History
N.C. is a member of the Travelling Community. She lives with her partner and four children and she is currently unemployed. She continued to smoke 3 cigarettes a day during pregnancy, cutting down from her prenatal 10 a day. She had occasional alcohol intake before pregnancy but none during.
DISCUSSION
N.C.’s care encompassed many issues that I will try to discuss here including the following:
• The effects of maternal smoking on birth outcome
• Complications of multiple pregnancy
• Previous placental abruption as a risk factor for another
• Indications for anti D administration in rhesus negative pregnant women
• Stillbirth management
N.C. a previous smoker of 10 cigarettes a day, attempted to quit but continued to smoke 3 cigarettes a day during this pregnancy. What pregnancy complications does this increase her risk of and how may pregnant women be encouraged to quit smoking during pregnancy?
It is well established that cigarette smoking has many adverse effects during pregnancy.(1) This includes spontaneous abortion, ectopic pregnancy, placental abruption, low birth weight babies, preterm premature rupture of membranes (PPROM), preterm labour and delivery and placenta previa.(2) It is quite evident in N.C.’s past obstetric history that she has had quite a number of these complications in the past, suffering 3 spontaneous abortions and having 4 babies born with birth weights below the average for their gestational age.
She has also had a previous placenta l abruption as well as the double placental abruption in this pregnancy. She also had all of her babies before term and one must wonder if some of these complications could have been avoided if N.C. had received more support and counselling in her attempt to quit smoking in each pregnancy. I know that during each pregnancy she tried to stop completely but ended up continuing to smoke a couple of cigarettes each day. She never tried any nicotine replacement therapy and I wonder if her G.P. should have done more to encourage this as this would be of great benefit in her attempt to quit completely.(3) This would have had a very positive impact on her pregnancies as well as her general health and her many complications would perhaps have been less likely if she had succeeded.
(3)
A multiple pregnancy, in this case, twins, increases the risk of many complications during pregnancy and so requires very careful management. How was this managed in N.C.’s case?
Once a multiple pregnancy has been diagnosed, hopefully before 14 weeks as was the case in this case, the type of twin pregnancy should be confirmed.(4) Twin pregnancies also require very close hospital based surveillance with regular scans(2, 4, 5), and N.C. received such care. Multiple pregnancies pose increased risk of fetal preterm birth, perinatal mortality, congenital abnormalities and obviously twin-twin transfusion syndrome is an important concern in monochorionicity.(5) There is also an increased risk of maternal complications e.g. postpartum haemorrhage, gestational diabetes mellitus and pregnancy induced hypertension, etc.(2, 5) Also a clear delivery plan should be made,(4) this had not yet been done in N.C.’s case due to her gestational age. A suspected twin-twin growth discordance of greater than 22% is an indication for care at a tertiary centre and N.C. was already receiving such care in Galway so no referral was needed.(4)
N.C. had previously had a placental abruption, which certainly predisposes her to another, what other risk factors were present and was the diagnosis made in a reasonable amount of time?
Placental abruption in a previous pregnancy is the most predictive predisposing factor to having another abruption. (6) A large Norwegian observational study reported a 4.4% rate of recurrent abruptions although some sources report this as up to 6%.(7) In those who have had 2 previous pregnancies complicated by placental abruption this increases to up to 25%(8). Other risk factors include pre-eclampsia, polyhydramnios, IUGR, low body mass index (BMI), multiparity, smoking, trauma and premature rupture of membranes(6). Certainly N.C. had several of these as she was had a previous abruption, was highly parous, smoked during her pregnancy, had an underweight BMI and had small for dates babies. Once N.C. presented to Admissions after visiting her GP on the Thursday, she was promptly sent for ultrasound where it was found that intra-uterine death had occurred of both foetuses. As such I don’t believe the diagnosis could have been made much quicker and I certainly feel that she was identified as a patient at high risk for placental abruption and treated as such(3). Unfortunately it was too late and therefore the management couldn’t really change.
N.C. a pregnant woman with the blood group O rhesus negative, has received anti-D antibodies in the past after certain potentially sensitising events, e.g. after ERPC, but did not after d2 of her miscarriages. What are the indications for administration of anti-D to pregnant women and were these followed in her management.
According to the RCPI guidelines, anti-D should only be given to women who are not already sensitised as it cannot reverse the process(9), and this was the case with N.C. They also state they should be given as soon as possible after the sensitising event, at least within 72 hours.(9) Even if this dose is missed they recommend giving the anti-D up to 10 days after the possibly sensitising event.(9) There is a list of potentially sensitising events after which anti-D must be given. These include: termination of pregnancy (medical or surgical), threatened or complete spontaneous abortion after 12 weeks, ectopic pregnancy, antepartum haemorrhage, invasive procedures such as amniocentesis, chorion villus sampling, fetal blood sampling, external version of the fetus, intrauterine death and stillbirth.(9, 10) This explains why N.C. did not receive anti-D after two of her miscarriages as they were before 12 weeks, and the one after which she did required an invasive procedure and so she received it in that case. She also received it after her stillbirth, which was appropriate. (9, 10)
I certainly learnt a lot from this case about management of an obviously very tragic case of stillbirth both in a more biological sense and obviously dealing with the patient and their family’s grief and coping with it.
Certainly the diagnosis of a stillbirth is one of the most tragic things that can happen to a woman and her partner, especially when it is so out of the blue. N.C. and her partner had previously suffered several early miscarriages, but the delivery of dead twin babies is clearly an entirely different matter. The news that an intrauterine fetal death has occurred should be delivered in a very unhurried fashion by the doctor looking after the woman and a midwife should be present.(11) It cannot be stressed enough that an IUFD should be treated as as serious a matter as the death of any other close relative and dismissals such as “You’re young you’ll have another”, etc are not appropriate.(12) A plan for delivery should be made as soon as appropriate and this should be in keeping with the woman’s wishes.(11, 13) Methods for induction now can be chosen differently as the effect on the foetus is of less importance.(11) In N.C.’s case a Caesarean section was chosen as it was a twin birth and also due to her three previous C-Sections.(14) In other cases a vaginal birth should often be considered, and also waiting for the woman to labour spontaneously, though this has an associated increased risk of disseminated intravascular coagulation (DIC).(11) Appropriate laboratory tests should be carried out to assess any maternal causes e.g. FBC, coagulation screen, serology for cytomegalovirus, toxoplasma and parvovirus B19, blood group and antibody screen, renal and liver function tests to rule out pre-eclampsia and HELLP syndrome, thyroid function tests and thrombophilia screens are all helpful in deciding if certain conditions attributed to the IUFD.(11) In N.C.’s case she underwent many of these cases even though a working clinical diagnosis of placental abruption had been made and this was found to be the case. It is also the case that fetal karyotyping should be offered as well as autopsy of the foetuses.(11, 13) In N.C.’s case the parents refused the right to a post-mortem as they believed they knew the cause of the stillbirth being placental abruption. This was then clearly taken as their decision and was clearly noted, they were not pressured into reconsidering. A post-mortem examination was still carried out,(11) noting that there were no obvious anomalies as well as noting the foetal weights, lengths, etc. Pathological examination of the cord and placenta was also carried out and the sizes of the clearly abrupted areas were noted.(11) I also noticed that the team were following the GUH checklist for a stillbirth which ensured that all relevant parties e.g. Public Health Nurse, G.P., Coroner; were informed as soon as possible.(11) The parents’ loss I feel was also very well recognised(13) and they received support from the Bereavement Liaison Officer as well as the chaplain. This was very comforting to the family as they wished for their babies to be blessed and for funeral arrangements to be made. Information on all of this was very clearly offered to them, especially through their midwife. N.C. and her partner were encouraged to keep the babies in the room with them as a way of recognising their grief and helping them to deal with it. They were also given the Little Lifetime pack where hand and footprints were taken of the twin boys and also photos taken with both their parents and themselves. I understand they found it difficult to look at these at the time but that they were still keen to have them for the future. A follow-up appointment with the consultant was made for 6 weeks’ time(11) and it was decided that the risks for future pregnancies and plans to conceive, very important in the Travelling Community would not be discussed until then.
REFLECTION
I certainly feel like I learnt a lot from this case both in an academic and also emotional sense. Obviously, I now know more about placental abruption, including risk factors, presentation and management; as well as multiple pregnancy, the impact of maternal smoking on the foetus and also administration of anti-D to rhesus negative women. Also I found out about the guidelines for management of a stillbirth and the clear checklists that they have available in this hospital for such. However I also certainly acquired a lot of practical knowledge about dealing with a patient in severe grief from my very brief encounter with N.C. herself as well as with the entire family. I know understand more about clearly recognising and acknowledging their grief as well as ensuring they have as many momentos, etc as possible for the future. It also really taught me about how quickly things can happen in obstetrics. In this case N.C. was not on the ward on Thursday and only came in late Thursday evening but by the time I saw her on the ward round Friday morning she (and her family) had gone from being very excited about their upcoming new arrivals to the absolute devastation of such a loss. It was pretty clear that while I saw her they were still trying to come to terms with what had happened and they seemed in a state of shock which is why I think the GP and Public Health Nurse have such a key role to play as I think it would often not be until the patient returned home, in this case two days later, that the reality of what had happened would hit and then they need as much support as possible. This is why in cases where the parents are working they should take as much parental leave as possible and this includes the father who can often be forgotten about in these cases. I definitely think that I know a lot more about the “other side” of obstetrics now that is an only too unfortunate reality as 1 in 200 infants in Ireland is stillborn, and I feel this learning experience will make a great impact on my future career as a doctor and also give me much more understanding of this terrible experience. I know that I will never forget the tragic scene in N.C.’s room when I first saw her on that Friday morning and the way in which the whole team did their best to help her sums up to me the my very positive experience on my Obstetrics and Gynaecology rotation.
1. Rodriguez-Thompson Diana MD M. Cigarette Smoking and Pregnancy www.uptodate.com: UpToDate; 2014 [updated 10/09/2014; cited 2014 20/09/2014].
2. Collins S, Arulkumaran S, Hayes K, Jackson S, Impey L. Oxford Handbook of Obstetrics and Gynaecology: OUP Oxford; 2013.
3. Gynaecology RCoOa. Antepartum Haemorrhage. www.rcog.org.uk: Royal College of Obstetrics and Gyanecology, 2011.
4. Institute of Obstetricians and Gynaecologists RCoPoI. Management of Multiple Pregnancy. www.rcpi.ie: Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland, 2014.
5. Impey L, Child T. Obstetrics and Gynaecology: Wiley-Blackwell; 2012.
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7. Rasmussen S, Irgens LM, Albrechtsen S, Dalaker K. Women with a history of placental abruption: when in a subsequent pregnancy should special surveillance for a recurrent placental abruption be initiated? Acta Obstetricia et Gynecologica Scandinavica. 2001;80(8):708-12.
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9. Institute of Obstetricians and Gynaecologists RCoPoI. The use of anti-D immunoglobulin for the prevention of RhD haemolytic disease of the newborn. www.rcpi.ie: Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland, 2014.
10. Gynaecology RCoOa. The Use of Anti-D Immunoglobulin for Rhesus D Prophylaxis. www.rcog.org.uk: Royal College of Obstetrics and Gynaecology, 2011.
11. Institute of Obstetricians and Gynaecologists RCoPoI. Investigation and Management of Late Fetal Intrauterine Death and Stillbirth. www.rcpi.ie: Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland., 2013.
12. Society ISaND. ISANDS Guidelines for Professionals. 1995.
13. Gynaecology RCoOa. Late Intrauterine Fetal Death and Stillbirth. www.rcog.org.uk: Royal College of Obstetrics and Gynaecology
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14. Institute of Obstetricians and Gynaecologists RCoPoI. Delivery after previous Caesarean section. www.rcpi.ie: Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland., 2013.